Be Excited!

So now, liberals have to fight hard for something they're not terribly excited about. A health bill will likely have a very weak public option or it won't have one at all. But liberals will have to battle for that bill as if it's life and death (which in fact it will be for thousands of Americans), because its defeat would constitute a historic victory for the birthers and the gun-toters and the Hitler analogists. In the coming weeks, building toward a possible congressional vote in November, progressives will have to get out in force to show middle America that there's support for reform as well as opposition, even though they may find the final bill disappointing.

This is what movements do – they do the hard, slow work of winning political battles and changing public opinion over time. It isn't fun. It isn't something Will.i.am is going to make a clever and moving video about, and it offers precious few moments for YouTube. It takes years, which is a bummer, in a political culture that measures success and failure by the hour. The end of euphoria should lead not to disillusionment, but to seriousness of purpose.

I'd go a step further than Tomasky: The upside of health-care reform is not that it's a defeat for the reactionaries. Rather, the upside of health-care reform is health-care reform. Four years ago, when the public option didn't exist as a popular policy concept, liberals would have been thrilled with the legislation we're seeing today. It's better than anything the major Democrats proposed in the primary, much less anything that passed four committees in Congress.

I keep recommending this Families USA brief (pdf, but worth it!) outlining the 10 most important elements of health-care reform. The public option is one of them, to be sure, and I think there's a substantial chance it will be present in the final legislation. But what about the expansion of Medicaid to 133 percent of the poverty line? That's a solid 20 million poor Americans who don't have coverage now, and will soon. What about the out-of-pocket caps, so no one goes medically bankrupt ever again? Or the assurance that no insurer can ever discriminate based on a preexisting condition? Or the subsidies for working Americans who can't quite afford coverage? Or the requirements that insurers spend more money on medical care and less money on premiums? Or the guarantee that the gruesome practice of rescission will finally end?

Obviously, there are a hundred ways that reform is going to fall short of not only perfection, but sufficiency. And the political compromises required to pass anything will dispiriting and inane. But it's worth keeping in mind that this bill is going to help a lot of people. Tens of millions. Hundreds of millions over the course of a few decades. It will mean that some of the very worst things that can happen to someone -- medical bankruptcy, or a cancer that strikes when someone is uninsured -- will, by and large, simply stop happening. That's worth being excited about.

"Obviously, there are a hundred ways that reform is going to fall short of not only perfection, but sufficiency. And the political compromises required to pass anything will [be] dispiriting and inane. But it's worth keeping in mind that this bill is going to help a lot of people."

Absolutely! As I watched the Sunday shows, I actually felt hopeful: there are few times when you see a group -- Conrad, Grassley, Lieberman, Lugar, Hatch, Specter, Schumer, and others -- delivering messages of practicality. Practicality isn't all that exciting at first, but ten years from now I think that it will be appreciated and remembered.

All good points, but, here's what I think you're missing about the importance of the Public Option. Without the public option, the insurance companies are told that their behaviors have been naughty, and they won't get to do them anymore, BAD INSURANCE COMPANIES! BUT! they will get a whole bunch of new customers (seems like rewarding bad behavior to me) AND, if those customers can't afford their policies, why, we taxpayers will just chip in and pay the difference!

Since no competition has been introduced there's no external pressure to insurance companies to lower/moderate prices or to stop raising prices, so we'll have to chip in more than we would if competition was introduced.

If I'm missing some mechanism that negates the above, please let me know.

If I'm not, the optics are that, after a slap on the wrist, the insurance companies will make out like bandits, partly because our tax dollars will flow into their coffers.
And I, who feel that these companies are despicable, will have to give money to one of them. I want a public option, partly because of the overall effect it will have on the entire playing field, and partly because the idea of giving any money to an insurance company makes me want to gag. (I am presently uninsured - pre-existing condition.) My hope is to be able to get coverage through the public option, and not through some company that can't be bothered to cover me now.

Thanks for a great and sensible piece. I am getting royally fed up with all of the negativity I am reading on liberal blogs. Do these people have any clue how far we have come on this? They seem ready to chuck the whole thing if it doesn't screw the insurance companies sufficiently.

If all we got was a catastrophic benefit with an out-of-pocket limit of 5 or even 10 thousand per year, that was universal and that you couldn't lose, that would be a huge, huge improvement over where we are now. As you say, it would pretty much end medical bankruptcies and would prevent most of the "horror stories" that we hear.

I want it all, too. But even if we don't get it all we can get something very meaningful, and something that can be a foundation to build on. This would be a stunning victory, although I'm afraid a lot of the left would see it as a loss. If they react by turning on Obama and the Deomcrats, we lose for sure.

Well stated, Ezra. Politics involves changing consciousness. And this country has long avoided the issue of the responsibility for the health care of the country. The assumption that a political party like the Democratic party has everyone on the same page in a governing majority simply ignores the fact that political parties are coalitions which easily fracture along cultural and special interest lines. We will get a bill this time and it will be the beginning of a long period of self-correcting towards a worthwhile goal.

In a few years if many are saying "I hate my health insurance and having to buy it." the dem respons is likely to be "A more serious crisis would have happened without it." And that will be a political loser.

That's one reason I think private option HAS to be in the bill. Otherwise it's just a bill where the insurance companies can blame their crappy service on Obama and the Dems... and make a defensible case for it.

And the Repubs will dismantle it all with their large subsequent majorities.

"Since no competition has been introduced there's no external pressure to insurance companies to lower/moderate prices or to stop raising prices, so we'll have to chip in more than we would if competition was introduced.

If I'm missing some mechanism that negates the above, please let me know."

Section 116 of HR 3200: "A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio."

"Section 116 of HR 3200: "A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio."

My guess is you've already seen it, but just in case not, I wanted to post a suggestion to watch the Bill Moyers show from Friday. Very moving and motivating, albeit in a much different way than this post.

Ezra, more people are covered and that's good, but speak clearly on another responsibility. You have to understand what you and Tomasky are committing us to, by a compromised reform. You are dedicating a big amount of peoples' attention in the future to new costs of maintaining and defending a complicated policy. This will once again include the continuous fight against capture by Wall Street insurance companies, in "a hundred [new] ways," such as by making future changes to Sec. 116. This will never end. It is great for us wonk types, but step outside our bubble for a moment. It has to be simple for people. A public insurance option could make it simple. And even after you make it simple, it's a tough fight. Three years ago they thought they could try again to privatize Social Security. Reactionaries have easier success, if reformers make it complicated, or make it so we still have to do more.

The left will NOT implement a constructive reform bill without the public option. They don't want reform -- they want single payer.

No actual fixes will be permitted if they will reduce the 46 million so important to the battle cry. No fixes can be permitted by the left if they reduce the urgency to implement single payer, or some option that could become single payer.

Actual reform is not allowed unless it includes a path to single payer.

"It's better than anything the major Democrats proposed in the primary, much less anything that passed four committees in Congress."

I'm at a loss here. The current legislation being talked about by the Senate Finance Committee is better than anything that was proposed in the 2008 Democratic Primaries?

I about 100% certain that completely incorrect.

Stop throwing 2004 at us. It's meaningless. 2004 is before we kicked the hell out of the GOP in 2006 and before we kicked the hell out of the GOP in 2008 with Healthcare being one of the central issue of the campaign. Obama and the various members of Congress didn't run on a 2004 platform in 2008.

You're consistently arguing for the second fall back position after we already fell back from Single Payer to a wildly watered down Public Option just to "get a deal". Not you're arguing that we fallback to Mandates that add tens of millions of people to the dole of the Health Insurance Industry with the "competition" being a Co-Op that everyone knows will either fail or "succeed" only if it gets taken over by Big Health as another Blue Cross/Shield.

This all would be laughable if it wasn't so depressing. Spare the "shiney" positives that leave the system utterly bankrupt. Let's just admit that all we care about is Coverage, and really don't give a crap about the Costs because those new Coverages are largely going to fall right into the lap of Big Health. It would be nice to shrug off this was done by the Bush Admin. But this is ours, with 60 Senators and a massive advantage in the House at their back... and it makes the process that much more painful. Nice "victory" for Rahm, which is all he cares about at this point.

I agree with Ezra 100%. How dare people - most of whom I would bet have good insurance - dismiss the lives saved, the bankrupcies avoided, the ER's not used anymore as primary medicine, the insurance recissions eliminated, the fear of pre existing conditions disqualifying one from coverage gone, etc etc as a sell out. No one is giving up on the public option yet. But if we have to ultimately at the time of the final conference committee vote, I'll still be damn proud that we started reforms that will benefit tens of millions of people.

"How dare people - most of whom I would bet have good insurance - dismiss the lives saved, the bankrupcies avoided, the ER's not used anymore as primary medicine, the insurance recissions eliminated, the fear of pre existing conditions disqualifying one from coverage gone, etc etc as a sell out."

Au Contraire: How Dare the insurance companies do these things in the first place? Or have you forgotten why all these tragedies occur?

I sorry... exactly what BK's are going to be avoided if our healthcare costs go up another 100% in the next decade?

Middle class and lower class salaries haven't grown in real terms in the past decade. Double my healthcare, and increase my deductable (which has been going up *every* year for the past 10 years), and I'll be in BK when the show drops.

Recision and prior conditions are nice bones to be tossed at us in this crap salad we're being forced to dine on like it's a filet. But it's not real reform doing much at all about our costs.

If it was all about "coverage" which you and Ezra and out President are now trying to sell to us, I would have liked to have him run on that back in early 2008 so I could have maxed out with HRC rather than putting my money with Barak. But that "hope" and "change" thing worked on me, and now I'm sitting here like an idiot. I really would rather be screwed over by four years of McCain than by the guy I supported. It just goes down easier when you can simply loath the person in the office rather than yourself for helping put your guy in that office only to support the real status quo of how DC opperates and who owns it.

sometimes i think that the unrelenting demands, complaints and pessimism on the left, are mirrors for what is happening on the right.
while obama is trying to thread needles and practice the art of the possible, it seems as though part of the left now, is just as gleefully determined as the right, to see obama fail.

"What about the out-of-pocket caps, so no one goes medically bankrupt ever again? "

Hey, Ezra,
Can you explain this? Is this really so? What happens when someone can't afford the out-of-pocket expenses? It's not far-fetched to imagine such a scenario. In such a case, as happens commonly today, the patient's name would be turned over to a collections agency, which often snowballs into financial ruin and the need to declare bankruptcy. What exactly can you point to that indicates this will not happen in the new bill?

"Section 116 of HR 3200: "A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio."

davis - can you explain that to me?

Posted by: Melinochis | August 24, 2009 4:25 PM | Report abuse

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I'll answer this. What he doesn't post is that this is set at 85% loss ratio. What it means is that in every state in the Union all insurers must pay out 85 cents for every dollar in premium. Currently the highest cap is 80% in several states and many states have no loss ratio requirements.

This idea that insurers will make windfall profits from the additional people covered will be false although many will still hold onto it.

While those are good endpoints, Ezra, the problem with simply passing laws like mandating that denial based on pre-conditions is illegal, or that there are no out-of-pocket caps, is that they're trying to attack an end-result without hitting the problems that are the source. It's like how CAFE system tried to increase automobile efficiency by demanding MPG increases, rather than changing the source of low MPG - cheap gas- by raising gas taxes.

It can work, but it requires good, competent enforcement agencies, and there are always, always efforts to end runs. The insurance company might be denied from simply refusing to give someone health insurance based on pre-conditions, but unless you mandate something like "community rating", they could simply set the premiums for people with pre-conditions so high that they can't afford to buy it en masse.

Or, they'll simply become much better at finding legal loopholes for screening purposes. Like timing policies so that they expire at a certain point and can't be renewed - conveniently at the point at which insurance becomes costly.

And that, of course, is ignoring the possibility that they might simply re-organize themselves into legal forms that can do screening and the like. Maybe they're not "insurance" companies anymore - they're "health maintenance" companies.